[Peetwo]

Lead Balloon back to ToRs - Part II

Slight drift here (from the DFO cover-up) but it is all IMO totally related (ie ATSB merely a top cover agency for the aviation safety autocracy and therefore for the Minister McDonaught -   )

Via Oz Flying (Warning: PROB > 30% that a bucket will be required for Hooded Canary comments on the linked ATCB media release and at the bottom of the page) :

 

 

ATC Action scrutinised after Mooney Crash
19 January 2021
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The actions of air traffic controllers have been put under scrutiny after the fatal crash of a Mooney west of Coffs Harbour in 2019.


Mooney VH-DJU was on a flight from Murwillimbah to Taree in September 2019 when it was refused a clearance to transit controlled airspace at 6500 feet, leading to the aircraft descending into non-VMC and colliding with high terrain. Two people on board the aircraft were killed.

The ATSB investigation report released today concluded that the information provided by ATC impacted the pilot's decision to descend, and that the pilot was not properly prepared for the conditions encountered.

“Information provided by air traffic control likely resulted in the pilot deciding to descend the aircraft from 6500 feet instead of other available safe options, such as proceeding around the Class C airspace at or above 6500 feet, diverting, or descending to the north of Grafton to proceed coastal beneath the cloud layers south to Taree,” said ATSB Chief Commissioner Greg Hood.

“The ATSB also found that the pilot was not carrying suitable navigation equipment–the pilot was likely using a handheld GPS unit while air navigation charts for the area were found stowed in a flight bag–and had most likely not obtained the required weather forecasts.

"These factors reduced the pilot's ability to manage the flight path changes and identify the high terrain. This led to the aircraft being descended toward the high terrain in visibility conditions below that required for visual flight, resulting in controlled flight into terrain.”

After being refused a clearance to transit at 6500 by a trainee controller, the pilot was given the option of contacting the Class D controller at Coffs Harbour, who subsequently advised the pilot that VFR flight would be possible only below 1000 feet due to cloud.

After announcing his intention to descend to "not above 1000 feet", the pilot diverted slightly west and descended to 4500 feet, infringing the C class airspace anyway. He then reported clear at 4100 feet and continued to Taree, before descending in the vicinity of the high terrain near Dorrigo.

The investigation also found that the pilot was not provided clearance to transit Class C airspace due to the trainee controller’s conservative assessment of their workload, although there was no conflicting traffic, meteorological factors or limiting air traffic control instructions or procedures that would have precluded providing the clearance.

The trainee’s supervisor accepted the assessment as an alternate option – transiting through Coffs Harbour Class D airspace – was provided to the pilot.

“The pilot was not provided with a clearance to transit Class C airspace despite there being no limiting meteorological factors,” Hood said. “Instead, the Class C controller provided the option to seek a clearance at a lower altitude with an increased risk of encountering poor weather.

“Further, the limited information provided by the Class D controller to enter that airspace probably led to the pilot’s decision to descend into a hazardous area instead of opting for other available safe options.”

During the investigation, the ATSB found that the pilot had also not completed the required flight reviews or proficiency checks.

"This resulted in the pilot not possessing the required licence to undertake the flight and likely led to a deterioration in the knowledge and skills required for effective flight management and decision‑making," the report states.

“This accident illustrates the significant influence that air traffic control can have on the conduct of a flight,” Hood added.

“And it also serves as another reminder of the risks for visual flight rules pilots flying into non-visual conditions.

“As a former air traffic controller and private pilot myself, I urge all current controllers and private VFR pilots to read this thorough and illuminating report. It contains pertinent lessons that others can learn from.”

The full report is on the ATSB website. 

 - Now back to ToRs, (beyond the Dick bashing -  ) via the UP: https://www.pprune.org/pacific-general-a...st10970864

Dick Smith

The ATSB final report has been released on the Mooney crash with two fatalities west of Coffs Harbour on 20 September 2019. Here is a link: https://www.atsb.gov.au/media/577925...-052-final.pdf

I believe the ATSB is deficient in this report because they don’t mention that the only way to operate Class C airspace satisfactorily in the terminal environment is to use an approach radar facility. The Minister’s directive of 2004 made this quite clear.

It is all very well to blame the air traffic controller and pilot, but to ignore a Minister’s directive with no explanation, and then not even cover it in the ATSB report, shows that something is going on here.

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Old Akro

Before we play the normal "pile on Dick" game. I think the point he is making is that there is a pre-existing directive from the Minister about use of approach radar in the airspace of the accident. If there is a Ministerial directive as Dick asserts and if AsA has not complied with this directive then subsequently there has been an accident that could have been avoided if AsA complied with the Minister's directive, then Dick is absolutely correct in suggesting that the ATSB has been deficient in its investigation.

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&..

Sunfish

So basically according to the Coroner, Airservices murdered the pilot and passenger. Judging by what happened to Glen Buckley, CASA murders the industry and judging by the quality of its reports, ATSB murders the truth.

How can anyone consider anything these institutions do as promoting safe aviation? All of these alleged behaviours encourage industry participants into unsafe behaviours.

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Finally Leady brings the thread full circle back to ToRs...

Lead Balloon

My view is that Airservices, ATSB and CASA are now effectively running a mutual protection racket. What’s not said in ATSB reports or not followed up by ATSB speaks volumes.

As another recent example, the ATSB report on the Renmark tragedy says:
Quote:

The operator’s training and checking manual procedure for simulating an engine failure in a turboprop aircraft was inappropriate and increased the risk of asymmetric control loss.
...
Despite the operator’s procedure being approved by the Civil Aviation Safety Authority (CASA), reducing the power to flight idle on a turboprop aircraft is not representative of the drag associated with a real engine failure as it does not take account of the beneficial effect of auto-feather/negative torque sensing systems. Consequently, had flight idle been selected it would have created significantly more drag on the ‘failed’ engine, making it more difficult to control the aircraft and achieve the expected OEI performance. While the operator’s procedure only required use of this power setting during the initial ‘phase one’ checks (which would be expected to be completed in less than 30 seconds), it has been a contributing factor to previous asymmetric loss of control accidents (for example AO-2010-019 in the section titled Related occurrences).

The ATSB sought information from CASA regarding the circumstances under which the incorrect procedure was approved for use by the operator. Despite this request, no information was provided by CASA. Consequently, the ATSB was unable to determine whether the approval of incorrect information was an isolated human error or symptomatic of a systemic deficiency with the approval process.

Well that’s OK then. Nothing more can usefully be done to find the truth. Move on, nothing to see here. Only three dead.

(Perhaps the deceased, including the CASA FOI, were among the critics of CASA identified in Mr Carmody’s ‘research’ as being the kinds of people likely to have accidents. Maybe those involved in the Mangalore tragedy, too...)

ATSB has powers to compel the disclosure of information, and the failure to disclose when compelled to do so is a criminal offence. The only people excused are coroners in their capacity as coroners. Those powers are there precisely to enable ATSB to obtain information when it is not volunteered, and that includes when not volunteered by CASA.

Although the procedure was - according to ATSB - “not necessarily contributory to the accident”, the procedure was - according to ATSB - “inappropriate and, if followed, increased the risk of asymmetric control loss.”

Wouldn’tcha think it might be important to find out whether CASA had insisted on the risk-increasing, folklore-based procedure to be in the operator’s C&T Manual, or whether CASA had overlooked the existence of the risk-increasing, folklore-based procedure in that Manual? If either of those were true, would it not follow that CASA may be part of the problem? And wouldn’tcha think it might be important to make a recommendation - or whatever the weasel word is these days - for CASA to find out whether the risk-increasing, folklore-based procedure is in other T&C Manuals and get the procedure removed?

The “safety issues and management” part of the report focussed on procedures for the safety of CASA personnel! “The [CASA temporary safety instruction’s] intent was to generally provide higher risk protection around operations involving CASA flying operations inspectors (FOIs).” Make CASA FOIs ‘safer’ and the job’s done!

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And Checklist Charlie puts down a (nailed it) dots-n-dashes OBS in reply to that...

 I do wonder if Lead Balloon's observation


Quote:

My view is that Airservices, ATSB and CASA are now effectively running a mutual protection racket. What’s not said in ATSB reports or not followed up by ATSB speaks volumes.

could perhaps be further explained by the career path involving all 3 organisations of the current ATSB Commissioner.

May be, maybe not!

CC

Must be high time for the Hooded Canary to sing me thinks??   

MTF...P2